What is the treatment for dorsal lumbar pain (lower back pain)?

From the Guidelines

For patients with acute or subacute low back pain, clinicians and patients should select nonpharmacologic treatment with superficial heat, massage, acupuncture, or spinal manipulation, and if pharmacologic treatment is desired, nonsteroidal anti-inflammatory drugs or skeletal muscle relaxants should be chosen. The American College of Physicians recommends nonpharmacologic treatments as the first line of treatment for acute, subacute, and chronic low back pain 1.

Key Recommendations

• For acute or subacute low back pain, nonpharmacologic treatments such as superficial heat, massage, acupuncture, or spinal manipulation are recommended, with moderate-quality evidence for superficial heat and low-quality evidence for the other options 1.
• If pharmacologic treatment is desired for acute or subacute low back pain, nonsteroidal anti-inflammatory drugs or skeletal muscle relaxants are recommended, with moderate-quality evidence 1.
• For patients with chronic low back pain, nonpharmacologic treatments such as exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction, tai chi, yoga, motor control exercise, progressive relaxation, electromyography biofeedback, low-level laser therapy, operant therapy, cognitive behavioral therapy, or spinal manipulation are recommended as the initial treatment, with moderate-quality evidence for some options and low-quality evidence for others 1.

Pharmacologic Treatment

• For patients with chronic low back pain who have had an inadequate response to nonpharmacologic therapy, nonsteroidal anti-inflammatory drugs are recommended as first-line pharmacologic treatment, with tramadol or duloxetine as second-line options, and opioids should only be considered in patients who have failed the aforementioned treatments and after a discussion of known risks and realistic benefits with patients, based on a weak recommendation with moderate-quality evidence 1.

From the FDA Drug Label

Clinical Studies Eight double-blind controlled clinical studies were performed in 642 patients comparing cyclobenzaprine hydrochloride 10 mg, diazepam, and placebo. Muscle spasm, local pain and tenderness, limitation of motion, and restriction in activities of daily living were evaluated The efficacy of cyclobenzaprine hydrochloride tablets 5 mg was demonstrated in two seven-day, double-blind, controlled clinical trials enrolling 1405 patients. One study compared cyclobenzaprine hydrochloride tablets 5 and 10 mg t.i. d. to placebo; and a second study compared cyclobenzaprine hydrochloride tablets 5 and 2.5 mg t.i. d. to placebo. Primary endpoints for both trials were determined by patient-generated data and included global impression of change, medication helpfulness, and relief from starting backache.

Treatment for back pain may include cyclobenzaprine hydrochloride tablets, as it has been shown to be effective in reducing muscle spasm, local pain and tenderness, limitation of motion, and restriction in activities of daily living in clinical studies 2.

• The recommended dose is 5 mg, taken three times a day.
• It is essential to note that cyclobenzaprine hydrochloride tablets should be used with caution in certain populations, such as the elderly and those with mild hepatic impairment.

From the Research

Treatment Options for Back Pain

• Pharmacologic management is a common approach for treating back pain, with acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) being first-line treatment options for most patients with acute mild to moderate pain 3
• Topical NSAIDs are recommended for non-low back, musculoskeletal injuries, while acetaminophen is well tolerated but should be used with caution in patients with advanced hepatic disease, malnutrition, or severe alcohol use disorder 3
• Adjunctive medications, such as muscle relaxants, may be added as appropriate for specific conditions, including acute low back pain 3
• For severe or refractory acute pain, treatment can be briefly escalated with the use of medications that work on opioid and monoamine receptors, such as tramadol or tapentadol, or with the use of acetaminophen/opioid or NSAID/opioid combinations 3

Conservative Management of Chronic Low Back Pain

• Conservative management is advised for chronic non-specific low back pain (CNSLBP), starting with reassurance and clear patient education about the condition 4
• Exercise within a multidisciplinary biopsychosocial rehabilitation program is emphasized, with positive outcomes including improved mobility, strength, and higher return-to-work rates 4
• Additional treatments, such as manipulation, massage, and acupuncture, can be considered, but their effectiveness is not well supported by evidence 4

Epidural Interventions for Chronic Spinal Pain

• Epidural interventions, including caudal, interlaminar, and transforaminal epidural injections, are effective for managing chronic spinal pain, with Level I evidence for long-term effectiveness in disc herniation and post-surgery syndrome 5
• Percutaneous adhesiolysis is also effective for managing disc herniation and lumbar stenosis, with Level II evidence for long-term improvement 5
• Epidural injections with or without steroids are effective for radiculopathy, with Level I evidence for local anesthetic with steroids and Level II evidence for local anesthetic alone 6